Success stories with challenging clients

By Lynne Shallcross October 10, 2010

“I don’t have to talk with you, and you can’t force me to talk with you.”

Not the ideal way for a counseling session to begin, but John Sommers-Flanagan didn’t let his young client’s rebuff stop him. Instead of fighting back with a clever retort, however, he simply told the client she was 100 percent right.

“I can’t force you to talk about anything,” said Sommers-Flanagan, an associate professor in the University of Montana Department of Counselor Education. “It’s completely your choice. In fact, if I ever try to force you to talk about anything, I hope you tell me, because I’m totally not interested in forcing you to do anything.”

After a short silence, Sommers-Flanagan went on to explain how he likes to work with clients in counseling. “You know, counseling is really weird,” Sommers-Flanagan told the young woman. “We’re total strangers, and yet, somehow, you’re supposed to walk in here, sit down and tell me about important stuff in your life. Well, I really don’t expect that. Instead, what I’d like to do is to begin by telling you what I’ve been told about you. I think that’s fair, because I’ve gotten information from your file and from your intake counselor. So I’m just going to tell you what I’ve heard, and you can tell me if it’s right or not.”

The approach helped Sommers-Flanagan, a mental health consultant with Trapper Creek Job Corps and a member of the American Counseling Association, make headway with the client. “First, when I conceded her power, it seemed to help her let down her defenses a bit,” he says. “Second, when I explained how I like to work with clients and that I didn’t expect her to be able to instantly tell me all her secrets, she seemed relieved. Third, when I told her that her file had said many positive things about her personality and her intelligence and then asked her if she thought that was true, she seemed genuinely and pleasantly surprised. This is probably because so many clients come to counseling expecting criticism and a focus on their personal weaknesses that it’s very reassuring when the counselor recognizes a positive strength.”

This type of start to the counseling relationship isn’t out of the ordinary for Sommers-Flanagan, coauthor with wife Rita Sommers-Flanagan of Tough Kids, Cool Counseling: User-Friendly Approaches With Challenging Youth, published by ACA. “Nearly every week, I meet with youth and young adults ages 16 to 24, and nearly all the students with whom I meet don’t want to meet with me,” he says. “This makes the initiation of the counseling process very difficult.”

A different light

Counselors might view particular clients as challenging for a variety of reasons, but it’s important to gain some perspective, Sommers-Flanagan says. “Historically, psychoanalysts referred to such clients as ‘resistant.’ Clients were viewed as resistant if they talked too much, talked too little, arrived late or arrived early, talked only about intellectual topics or only about other people, or disagreed with the ‘all-knowing’ psychotherapist or counselor. In other words, depending on the individual client and counselor, nearly any behavior can be seen as challenging or difficult.”

More recently, applying the resistant label has been frowned upon because it is viewed as blaming the client. Instead, Sommers-Flanagan says, words such as challenging, reluctant or precontemplative are used. “However, even though the intent of using these less pejorative terms with clients is positive, these words still lay some blame on clients for their ambivalence or for not being ready to accept the help the counselor has to offer,” he says.

An important question for counselors to ask themselves is whether clients deserve the blame for being challenging or whether counselors should be held responsible for having the right tools to help, Sommers-Flanagan says. “I think the answer to this is that although clients — including angry and challenging teenagers or substance-abusing clients — may behave defensively, the counselor should always take personal and professional responsibility for having enough competence to connect with and work effectively with even the most defensive clients. In fact, we should try to remember that the whole counseling scene may feel quite weird or uncomfortable to clients who aren’t used to talking with a virtual stranger about their most intimate problems.”

Mark Woodford, an associate professor and chair of the College of New Jersey Department of Counselor Education, agrees that even referring to clients as “challenging” can hinder the counseling process. “My experience is that these labels can get in the way of my clearly seeing and hearing what clients might be saying about why they don’t want to participate in the counseling process at that point in their lives,” says Woodford, a member of ACA. “So if I feel resistance to the process — that is, a client is challenging me about something that I have said or done — then I use that as clinical information about how I am managing the therapeutic relationship. Specifically, I ask myself if I am accurately gauging where my clients are in terms of their readiness to participate in counseling and/or to change whatever it is about themselves that has brought them into counseling.”

Some clients are mandated to come to counseling by the judicial system, an employer or even a family member, Woodford says. “If this is the first time they are even thinking about the issue in question, then they may be in the precontemplation stage of change. My work [as a counselor] will involve more empathy and active listening at this stage to help them raise their consciousness about whether or not they even want to contemplate making any changes at that time. If I move too quickly into helping them to actively make a change and they are still ambivalent about doing so, then I will feel the resistance.”

Rita Sommers-Flanagan, professor of counselor education at the University of Montana, concurs that mandated counseling can create a challenging situation, particularly if the client doesn’t perceive the need for it or embrace the potential benefits. “Similarly, youth whose parents are making them come or romantic partners who are only getting counseling because their partner threatened to leave are also examples of the less-than-enthused client,” she says.

Challenging counseling situations can also stem from clients lacking the resources to make the changes they want to make or otherwise facing nearly insurmountable barriers, says Stephen Southern, president of the International Association of Marriage and Family Counselors, a division of ACA. Still other clients are simply unaware of what needs to be changed, he says.

Whatever the situation, each client is unique and will thus have unique reasons for being defensive, John Sommers-Flanagan says. He points to Irvin Yalom, the group therapist who emphasizes that resistance and reluctance generally are associated with pain avoidance. “If we start with the hypothesis that clients are challenging because they’re reluctant to face and deal with their emotional pain and then try to gently explore client strengths as a means for eventually approaching the pain, the counseling process is likely to proceed more smoothly,” Sommers-Flanagan says.

Making inroads

When confronted with a challenging case, counselors should first focus on their own self-awareness, Sommers-Flanagan says. “In counseling, we emphasize self-awareness as a first step for working effectively with diverse clients, and in some ways, clients who behave defensively are another type of diversity. As a consequence, the first step for counselors is to look at ourselves and see how we might be contributing to an environment that is viewed as threatening or not entirely conducive to counseling.”

Understanding the concept of change can also be a help to counselors, Southern adds, pointing out that James O. Prochaska and John C. Norcross described six stages of change: precontemplation, contemplation, preparation, action, maintenance and termination. “They emphasized that change is a process that evolves over time. At each stage of the behavior change process, different interventions can be matched to client needs to produce progress,” says Southern, professor and chair of the Department of Psychology and Counseling at Mississippi College.

Many addicts and their family members are contemplative or precontemplative, according to Southern, who edits The Family Journal and the Journal of Addictions & Offender Counseling. “These are very challenging clients because they are suffering, but we really cannot help much. Counselors should avoid action-oriented approaches early in the change process. The clients are just not prepared. Counselors can be helpful with these challenging clients by nurturing, encouraging and gently guiding them to examine consequences of remaining the same and promises of genuine changes in small steps.”

Woodford has had numerous experiences counseling mandated clients who did not want to be in counseling and has found the skills required to succeed in those situations include expressing empathy, developing discrepancy, avoiding argumentation, rolling with resistance and supporting self-efficacy. Woodford adds that he first works to align himself with the client as an ally so the client doesn’t view him as an extension of the problem. “When they realize that I can help them or that the counseling process can help them to move through whatever challenges they are facing, then a light will turn on, and you can see in their nonverbal behaviors and in their verbal stance with you that a shift has occurred in the therapeutic relationship. That is often a pivotal turning point. At that point, the counseling skills move more toward helping the client to prepare for change and discussing what action steps can be made to make change happen.”

Woodford recommends five strategies based in motivational interviewing to break through barriers with clients and move forward with counseling: Ask open-ended questions, affirm and support, listen reflectively, summarize and elicit self-motivational statements. “I also use a ‘decisional balance’ technique that helps clients to weigh the pros and cons of making changes versus staying with the status quo,” he says. “I find this very helpful to make explicit what their thoughts and feelings might be about the potential for change at that point in their lives.”

Move aside

“With all forms of resistance and challenge, one great strategy is to simply get out of the way,” Rita Sommers-Flanagan advises. “Be understanding, listen carefully, reflect wisely on what you hear, but do not step into the fray. Let the client work out his or her internal resistance by providing a safe, nonjudgmental environment that will allow things to unwind.”

Another strategy she recommends is to ask clients to talk about the idea of counseling or their fears or anger associated with it. The counselor can then agree that the client’s reasons for being angry or cautious are valid, while also commending the person’s commitment to participate. “I’d be upset, too, if my wife said I had to come or she would leave,” Sommers-Flanagan might tell a client. “That’s a tough one. Here you are, sitting with a stranger, trying to do something to please her. Wow, you must really care about her to take this kind of risk.”

Among John Sommers-Flanagan’s preferred techniques are sharing or conceding power to the client, acknowledging the awkwardness and difficulty of counseling sessions, disclosing what he has heard or read about the client and sharing how his counseling approach does not include pressure. He also recommends maintaining a consistent focus on client strengths, engaging in active listening, using humor when appropriate and emphasizing that clients are the real experts on their own lives.

He adds that the person-centered theoretical foundation of congruence, empathy and unconditional positive regard is important in difficult counseling situations, as well as a concept called “radical interest.”

“The essence of radical interest is for the counselor to experience the feeling of being deeply interested in the life and perspective and emotions of this other person in the room,” he says. “In some ways, it’s the indirect communication that, in the moment, the counselor’s No. 1 interest is to listen to and understand whatever’s going on in the client’s world.”

Framing the counseling process as a consultation can be helpful with younger clients, Rita Sommers-Flanagan says. “With an angry young person, I might say, ‘You really don’t want to get into this counseling stuff, and I don’t blame you. But here’s the deal. You have this problem of needing to be here, so maybe we can just consult together on how to solve some of the situations that got you here — sort of like I’m your hired consultant. What would that be like?'”

When young people say they don’t want to talk about something, she tells them they don’t have to talk about anything they don’t want to. “Then I pause for a second and say, ‘But I am curious. If you did decide to talk about it, what do you think the most important stuff would be?’ Surprisingly, some actually launch into the painful or infuriating or frightening material. Others call my bluff, and I just say, ‘That’s fine. We really can talk about something else.'”

At the end of the day, she says it’s important for counselors to remember one piece of advice: Don’t take it personally when clients don’t automatically embrace the counseling process. “Imagine that you are just stepping in for all the disappointments, indignations, abusive interactions, misunderstandings and failings the client has faced. It isn’t about you — it is about their defensive system kicking in to take care of their pain.”

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In the trenches

Counseling Today asked various ACA members to share anecdotes about their experiences with challenging counseling situations or instances in which client progress appeared stalled. Read on for their lessons learned and how they and their clients reached a turning point in the counseling relationship.

Rick Carroll is a counselor with the Children’s Advocacy Center of Bristol/Washington County, Va.

“While working with male adolescents in an outpatient counseling setting, I often encounter initial resistance with this population. Most male adolescents are the last ones to think they need ‘counseling,’ and this mind-set was no exception for ‘Billy.’ Billy was a 14-year-old who had experienced years of sexual abuse from his stepfather. Once the abuse was uncovered, Billy was removed from the home and placed in foster care. This young man was a) angry that he had to leave his home, especially when everyone told him he did nothing wrong and the abuse was not his fault; b) confused as to why he needed counseling; and c) embarrassed when confronted with the idea of having to disclose his sexual abuse experiences. Since Billy’s abuser was an adult male, the same as his new therapist, the transference was noticeable from the first session. After three tedious sessions of receiving only one-word answers — when he spoke at all — and minimal eye contact from Billy, the fourth visit proved to be our breakthrough session.

“Billy arrived at that session in a particularly raw mood. Instead of going upstairs to the office, he was asked if he would like to learn a little about the game of golf. Billy scoffed initially at the idea, stating golf was for ‘pretty boys and snobs.’ However, after challenging him to a long-drive competition, with the prize being a pack of gum, he accepted the invitation. This outing was successful in several ways:

After several failed attempts to make contact with the ball, he was able to ask for assistance, surrendering to the help of others.

He became frustrated with his lack of ability but stayed in control of his anger.

He was able to see another side of this therapist and trust this adult male enough to venture outside the familiar counseling setting, realizing not all adult males take advantage of children.

He learned how golf mimics life — you have to play it where it lies, be aware of the hazards and understand that keeping focused and in control always produces better results.

“Using an experiential, hands-on approach to counseling, we were able to redefine the nature of our time together and make the learning and healing process more enjoyable. We were also able to process how the skills learned during our sessions could be used in other settings, such as at home and at school. Billy was noticed to speak more freely about his past experiences when we were playing golf, and he even asked for his sessions to be increased to once per week.”

Jeffrey Guterman is an associate professor of counseling at Barry University in Miami Shores, Fla., and the author of Mastering the Art of Solution-Focused Counseling, published by ACA

“In the late 1980s, I had been working with Susan, a 49-year-old woman with a history of bipolar disorder. At the time, I was a licensed mental health counselor in a group private practice and also working toward my doctoral degree. I was only four years out of graduate school and in a liminal stage between two diverse orientations: rational emotive behavior therapy (REBT) and solution-focused therapy.

“Susan would have been a difficult client for an experienced counselor. Being relatively new in the field, I found myself working with an especially challenging client. Family crises and suicide threats were the norm for Susan. Change seemed to come slowly, if at all.

“When Susan canceled a scheduled appointment with less than 24-hours’ notice, she went ballistic upon learning that she would be required to pay my fee out-of-pocket. I wasn’t surprised when Susan started our next session with a challenge. ‘You’re asking me to pay your fee because I canceled with less than 24-hours’ notice? Well, let me ask you something! If you ever have to cancel one of our appointments and you don’t give me 24-hours’ notice, will you agree to pay me your fee? I think that should be how it works. It’s only fair! Don’t you think?’

“I thought for a moment and then I quickly agreed. ‘You’re right! It works both ways.’ And we shook on it. An air of cooperation suddenly spread through the room, and we proceeded to have the best session ever.

“Later that week, I shared my experience with several colleagues. One colleague strongly disagreed with how I handled the situation and insisted that the counselor should always be in charge. I thought to myself that such thinking is the stuff that resistance is made of.

“After this event, everything began to change in the counseling: Susan, the counseling relationship, me. Susan felt empowered. She enacted personal agency. The counseling shifted from an emphasis on problems to a focus on solutions. We were now organized around Susan’s strengths and resources rather than her weaknesses and limitations. I also found that I was liking my client more. But nothing had intrinsically changed about Susan. The difference was largely a shift of perception — of hers and mine. The potential for a collaborative counseling relationship was always there, as was Susan’s and my solution focus.

“For me, this case crystallizes a personal shift from an educative, REBT approach to a solution-focused sensibility because it dramatically allowed for new possibilities for what had up until then been a most ‘difficult’ client.”

Valerie Zaffos earned her master’s in mental health counseling and is doing her postgraduate internship at Jewish Family Services in Plantation, Fla.

“I like to describe ‘Joe’ as a ‘salty dog’ — a seaman through and through. Though debilitating physical injuries forced him to forgo his beloved work as a yachtsman and charter boat captain years before he entered therapy at age 53, Joe dressed the part anyway: a baseball cap with a logo for a marlin fishing tournament, jeans and a t-shirt that reeked of marina engine oil, even though it had been freshly laundered. He came for treatment of a major depressive episode triggered by recent stressful events, including loss of disability insurance, which in turn contributed to dire financial straits and the inability to procure narcotic-strength pain medications to manage chronic and debilitating knee, hip and shoulder injuries.

“Our sessions followed a pattern almost from the get-go. Joe would recount a recent stressful event, start to feel the emotional pain and abruptly shift to racist rants on the societal issue of the day. It wore on me to witness them. Eventually, it dawned on me that the rants were Joe’s defense mechanism, allowing him to stay [one step removed] from his own sense of powerlessness and incompetence by projecting those judgments onto easier targets. It also helped that I was able to find other aspects of this client’s colorful personality to like.

“The next time Joe morphed from boat captain to blowhard, I mustered as much empathy as I could and softly interrupted him: ‘Joe, it must be so difficult for you to feel so strongly one way and yet feel like you have to behave exactly the opposite out in public.’ It was as if the wind went right out of his sails. Joe quieted, and I had my ‘way in.’

“‘I don’t want people to think I’m a bigot,’ he said. This admission led to a powerful discussion of Joe’s motivations, his fear of harsh judgment, his feelings of powerlessness. Ultimately, Joe discovered that he was not at the mercy of the wind. He could move under his own power and trust his decisions.

“It is no coincidence that as Joe developed a sense of self-efficacy, the rants and slurs disappeared. He finally felt safe to explore his pain, to take responsibility for his choices and to approach his life from a perspective of personal power. Ironic that unconditional positive regard for a universally bigoted client is what turned him around.”

Sandra Kakacek is an adjunct professor at Northern Illinois University and works in private practice in Maple Park, Ill.

“The journey of counseling new clients is always paved by eager anticipation and searching my therapeutic skills to provide the best interventions possible as the process of cocreating change unfolds. One client recently has been an excellent example of a challenge. The client and I needed to learn each other’s language to forge an understanding of desired outcomes and construct mechanisms for processing information. Throughout sessions, both the client and I continually checked and rechecked understandings. I learned the uniqueness of his ‘thinking,’ as I believe he did from me.

“Sam is an older male in his 60s diagnosed with Asperger’s. He sought a unique, creative format for counseling to explore his newfound revelation that he emphatically repeated: ‘I think differently than most people.’ Sam sought counseling after a divorce [that followed] marital counseling. He spent four months researching to understand himself and his needs. He entered counseling with the goal of developing coping strategies to construct social relationships.

“We engaged in experiential activities using equine-assisted counseling. Although I have had the pleasure of using equines for nine years for a myriad of mental issues and ages, I was amazed at the insights and awareness Sam gained rather quickly as he methodically worked with horses. He wrote copious notes following each session to chronicle the changes in his world and asked specific questions of me as he began to unravel how to adapt.

“The first exercise was to observe the nonverbal dynamics of a small group of equines. Sam, with his hands tucked in his jeans, walked up to three horses. When the horses each moved away, he declared, ‘They ignore me like everyone else.’ His analytical and linear perceptions became metaphors for the changes he needed.

“The turning point came during the sixth session. Sam was given the exercise of haltering a horse and moving him through an obstacle. Sam haltered the horse with some difficulty and, as he was walking the horse over an obstacle, the horse pushed into him. Sam’s reaction was, ‘Wow, I did not notice the horse so close to me. That is what happens to me all the time — at the store, at work and anytime I am around people.’ He began that day to become acutely aware of others’ nonverbal interactions. This eventually resulted in picking up not only people’s nonverbal communications but their verbal communications as well. The creative use of equine-assisted counseling provided a unique opportunity for change utilizing metaphorical properties.

“Sam has used his newfound adaptive skills to enter into new relationships. His rigidity has diminished, and he is keenly aware of what he is reacting to and can take time to process now when needed. I have been a recipient of Sam’s exploration and have been gifted by his continual processing to understand Asperger’s in adults.”

Louise Holzhauer is a member care counselor and registered mental health counselor intern with Orangewood Presbyterian Church in Maitland, Fla.

“Laura was my first long-term client after completing my master’s degree in counseling. I was nearly as frightened as she was when she arrived for her first appointment with the words ‘HELP ME’ carved into her ankle with a box cutter that she carried in her purse. Laura was deeply depressed and suicidal, anxious and dependent on everyone in her life, especially her husband, who was threatening divorce. She had suffered repeated sexual abuse as a child and believed that she was damaged beyond any value.

“Laura began to make progress almost immediately on many fronts. She was on a journey of spiritual renewal, which challenged her with the truth of her own worthiness. She also attended group counseling for her past abuse. However, the biggest immediate change I saw in her came as the result of my impromptu suggestion that she try treating her husband as a stranger for one week. Previously, she had been unable to detach herself from him, working continuously to anticipate his needs, interpret his nonverbal cues, assume his emotions and stave off his criticism, real or imagined.

“When she came to her next session after treating him like someone she’d ‘just met in the grocery store aisle,’ she was a changed person. She’d spent a happy week of freedom from her emotional prison, and her husband had enjoyed it, too! While she has had her ups and downs since then, Laura and I both had our eyes opened that day to the profound ramifications of a simple change in perspective. Attachment theory informed this intervention, which might be classed as rational emotive behavior therapy.”

Barbara LoFrisco works in private practice in Tampa, Fla., where she offers individual, couples and sexual counseling

“Recently, I worked with a very challenging couple. As with many couples, the intimacy in their relationship had deteriorated to the point where they were constantly arguing. Resentments were piling up. Sessions were heated, with one of the partners very angry because her intimacy needs had not been met for a very long time. The other partner seemed detached and unwilling to participate, although he reported that he still loved his partner and wanted to save the relationship.

“I started out trying to conceptualize the etiology of the problem. I got a lot of ‘I don’t know’ and ‘I don’t remember’ responses. I tried externalizing the problem. That didn’t work either. I tried a listening exercise. Again, no. I tried nonphysical intimacy building — conversation starters, date night. Nope. At this point, one of the partners suddenly announced she wanted to separate. Things looked bleak.

“I was having a difficult time trying to figure out exactly what was going on. I was able to identify a feedback pattern, which I discussed with the couple. Although I had a handle on how their interactions were exacerbating the problems in their relationship, both partners resisted making the necessary behavioral changes to break the cycle. I was stuck.

“At this point, I turned off my brain and stopped thinking about techniques and theories. I turned on my empathetic self and just listened. I heard fear, desperation and hurt. I connected with their pain. I helped them communicate their pain and fear to their partner. Inadvertently, I was using emotionally focused therapy, although at the time I did not make a conscious decision to do so. It just came naturally and from the gut. The previously uncommunicative partner started opening up. I began to understand what had been happening. That was a breakthrough moment for this couple. Although my work with them is ongoing, now that I have a better understanding of the dynamics, I have increased hope and confidence of helping this couple restore their relationship.”

Teri Echtenkamp is a child/adolescent program therapist with Alegent Health Systems in Omaha, Neb.

“It’s not that I have a particular challenging client in mind but rather a challenging population that I work with. I am a child/adolescent inpatient acute care counselor and work in crisis stabilization with psychiatric clients and their families.

“Inpatient acute care is a curious beast. The client is hospitalized usually three to five days and, for the most part, I only have the opportunity to have one family session. In the beginning, my focus was safety planning, home behavior contracts and discharge planning. Much continued conflict, negativity [and] lack of forward direction occurred and, many times, discharges had to be canceled due to the volatility of emotions. I struggled for at least six months with inadequacy, burnout and a lack of feeling much was achieved during these sessions.

“Once I got off my pity pot, I started reading anything I could to enhance my understanding of family therapy and brief interventions and started applying integrative, solution-focused techniques. I actually found a miracle in a modified ‘miracle question.’ I ask the family to fast-forward 45 minutes and see themselves thinking, ‘That went good. That was productive, and I’m glad we met for a family session.’ Then I ask each individual, ‘What would have happened here?’ Mind you, I still use concrete interventions from a variety of approaches, including cognitive and behavioral. However, I have learned to focus on emotions versus behaviors, solutions versus problems, externalizing versus internalizing, exceptions to the rule versus rules, all of which I have found instill hope, empower and increase communication.

“Due to my approach evolution, what was once an overwhelming burden now becomes my highlight. I’m energized by families’ hard work in creating their own solutions, awed by the bravery and healing energy of my clients and their families, and convinced of the power and effectiveness of using an integrative, strength-based, solution-focused methodology within my very limited one-session-only constraints.”

Rita Sommers-Flanagan

“I once saw a man who was coming in because his partner said she would leave him if he did not. He was very closed and angry at first. He worked as a car mechanic and was very good at it. After empathizing with him about how bad it feels to be forced to do something, I asked him about how he had become a mechanic and how he had gotten such a great reputation. This allowed him to share some history that had nothing to do with the relationship problems.

“After a couple of sessions of getting to know him, I offered him the notion that people and relationships, just like cars, need maintenance, and that in some ways, that’s what his counseling was like. We were simply ‘changing the oil’ and ‘checking the belts and fluid levels.’ We did this with some level of humor, and he was able to relax and talk about how his oil had gotten both a bit dirty and quite low and how that made the engine of the relationship run hot. … You get the drift.”

Helena Collins is a counselor working in private practice in Memphis, Tenn.

“‘Mr. M’ was a 31-year-old Spanish-speaking male who had attended my domestic violence group for court-ordered people about four years ago. Because of DV related matters Mr. M had separated from his 27-year-old Spanish-speaking wife, ‘Mrs. J.’ About four years after his completion of the 24 classes on domestic violence Mr. M sought counseling from me for depression, jealousy, mild domestic violence episodes and child visitation issues. During our second therapeutic meeting, Mr. M asked me if he could invite the mother of his two minor children to join him in therapy. I informed him that (it) would be appropriate if he wanted to work on issues related to child visitation or if he still wanted to try save their marriage. I further informed him that I would keep confidential everything he had already shared with me, except the exceptions for confidentially according to state laws, if his wife would join him in session.

“The next weekly session, Mr. M arrived early at my office and introduced Mrs. J to me as the mother of his two minor children. From the first session, Mrs. J exhibited an overall shy personality type. I took a significantly long time explaining to her the informed consent prior to obtaining her signature. She informed me that she was going to place her signature below her husband’s — now separated — name because in their culture man comes first. I explained to her that since both of them were adults, I do not make such gender-based distinction. I further stated that she could even write/sign above his name and that such would not indicate that she was either in charge/control of him or would receive preferential treatment.

“I worked with this case for several months, during which (time) we addressed many personal issues, which appeared to have negatively influenced their abilities to get along and respect each other’s boundaries. (That) in turn resulted in their separation and present struggle about child visitation. As we progressed into the therapeutic process, the couple started gaining significant insight into their approaches to life, self, the external world, responsible parenting, the harmful consequences of domestic violence on the children’s development and the view that ‘you are not an object of your partner’s possession.’

“During session five or six, they came to my office holding each other’s hands. They had a big smile and an overall relaxed expression. Gladly Mr. J announced to me that after so many sessions they have decided to save their marriage. “We are now together again, and I am now pregnant with his third child.”

“As they continued to improve in terms of their relationship, I started spacing sessions and working toward closure of their case. Finally, at her ninth month of pregnancy, they came for the final session. They entered my office and sat in two separate chairs but very close to each other. Mr. M looked into my eyes and said: ‘We came here today for two reasons: We want to thank you for your help and we want you to name our baby boy who will be born in two days.’

“Mr. M’s request caught me off-guard. I was wordless. I, however, had to respond appropriately according to the context and my role as mental health provider. I replied to him, ‘I am the one to say thank for the opportunity you gave me to assist both of you when you needed it the most. I am also honored with your request. But unfortunately, I see that we both have wasted our time because you appear not to have learned anything either from the 24 DV group sessions four years ago and during these nine months we have been working together.’ ‘What do you mean?’ he asked. I prompted him: ‘Who is supposed to be the most important person for you?’ He said, ‘Me. I have learned from you that I must first take care of myself so I may become able to love/assist those I love.’ I said, ‘Great! Now, tell me, who is supposed to be the second person for you?’ ‘My wife,’ he said. ‘Fantastic!’ I said. ‘I see you have indeed learned something from the sessions we had, but I cannot find congruency between your statement and such a request. Explain to me and justify your request for me naming your unborn child. If indeed you are putting into practice what you told me above, how then you ask me to name your new child? Please turn to your wife and discuss this intimate matter with her.’ At that moment they looked and each other, placed their chair very near of mine, placed their hands on my right hand and stated into one single voice: ‘We already discussed this issue at home and we want you please to name our unborn child.’

“I lost one dear son when he was just 9, 31 years ago. It was too much for me. I excused myself and cried for a moment in the bathroom. I quickly composed myself prior entering the office and told them, ‘Yes, I am going to grant you such request of naming your child under one condition. That from this moment on you will promise to yourself, your wife and your children, including the one arriving in two days, that you will never again, under no circumstance, place your hands on this woman in an abusive manner or speak to her in a disrespectful way.’ He did swear to me that he would keep his promise. ‘Your son is going to be called Marcus Fabio, which is my dear son’s name,’ I said. The next day, I found myself shopping for a baby boy.

“One time more God helped me to assist one more family in distress even thought I was not able to assist my own self after 13 years of enduring domestic violence. Mr. M finally appeared to have learned that the importance of his role, not only as husband and father but especially, he started acting as a real man instead of being the macho in control of his wife. For her, I do believe that in many aspects she would profit from further therapy. Besides, when reflecting on my unconscious decision to give their child the same name of my own deceased child, I started perceiving that even though almost 31 years have already passed I did not heal completely yet from the loss of my own child.”